Features on Computed Tomography That Correlate With Acute Appendicitis.

Background: The purpose of this study is to investigate the relevant findings in adult patients admitted to Cabell Huntington Hospital who were diagnosed with acute appendicitis. Methods: Patients who had the postoperative diagnosis of acute appendicitis and a preoperative computed tomography (CT) scan from January 2011 through December 2016 were included in this retrospective chart review. Results: There were 592 patients. A thick, edematous appendix was the most common CT finding in acute appendicitis. The average diameter was 12.6 mm. The wall thickness correlated to the diameter of the appendix (P < 0.001). For comparison, we reviewed the CT scans of 50 trauma patients who had normal abdominal CT scans. The average diameter of a normal appendix was 4.9 mm (SD 1.139) with a range of 4-7 mm. Interestingly, the admission white blood cell count (P = 0.0372) as well as the thickness of the appendix (P < 0.0001) were strongly associated with increased length of stay. Conclusions: An appendiceal diameter greater than 9 mm should be considered abnormal and associated with acute appendicitis. Appendiceal size, white blood cell count, and age correlate with length of stay. Early antibiotics and early surgical intervention may decrease length of stay.

Impact of MRSA polymerase chain reaction (PCR) wound swabs on antibiotic de-escalation in skin and soft tissue infections.

Methicillin-resistant strains of S. aureus (MRSA) polymerase chain reaction (PCR) testing is a laboratory test that allows for rapid detection of MRSA and is available to use in skin infections via wound swab. There are limited data demonstrating the utility of MRSA PCR wound swabs on clinical outcomes in skin and soft tissue infections. This retrospective, single-center study included 652 patients to determine if the use of a MRSA PCR wound swab in skin infections results in a more rapid de-escalation in antibiotics. Patients with a MRSA PCR negative wound swab demonstrated a 1.0 (-1.5 to -0.53) day reduction of anti-MRSA antibiotic usage compared to those in the control group who did not have a MRSA PCR available (wound culture data only) (P < 0.001, unadjusted). The results of this study demonstrate that MRSA PCR wound swab assays have the potential to play a significant role in antibiotic de-escalation in the setting of skin and soft tissue infections.

Profiling of Non-Coding Regulators and Their Targets in Epicardial Fat from Patients with Coronary Artery Disease.

Epicardial fat is a continuously growing target of investigation in cardiovascular diseases due to both its anatomical proximity to the heart and coronary circulation and its unique physiology among adipose depots. Previous reports have demonstrated that epicardial fat plays key roles in coronary artery disease, but the non-coding RNA and transcriptomic alterations of epicardial fat in coronary artery disease have not been investigated thoroughly. Micro- and lncRNA microarrays followed by GO-KEGG functional enrichment analysis demonstrated sex-dependent unique mi/lncRNAs altered in human epicardial fat in comparison to subcutaneous fat in both patients with and without coronary artery disease (IRB approved). Among the 14 differentially expressed microRNAs in epicardial fat between patients with and without coronary artery disease, the hsa-miR-320 family was the most highly represented. IPW lncRNA interacted with three of these differentially expressed miRNAs. Next-generation sequencing and pathway enrichment analysis identified six unique mRNAs-miRNA pairs. Pathway enrichment identified inflammation, adipogenesis, and cardiomyocyte apoptosis as the most represented functions altered by the mi/lncRNAs and atherosclerosis and myocardial infarction among the highest cardiovascular pathologies associated with them. Overall, the epicardial fat in patients with coronary artery disease has a unique mi/lncRNA profile which is sex-dependent and has potential implications for regulating cardiac function.

Assessing Colorectal Cancer Screening Barriers in Rural Appalachia.

OBJECTIVES: The age-appropriate colorectal cancer (CRC) screening rate in the rural Appalachian area is low compared with the national rate, which may account for the overall higher incidence of CRC in this area. The purpose of this study was to explore potential barriers to CRC screening in the West Virginia Appalachian area. METHODS: A cross-sectional survey was designed to identify patient-reported barriers to CRC screening using the health belief model to assess their attitudes and behaviors. Autonomous paper-based surveys were randomly handed to individuals older than 50 years at various locations, including healthcare and nonhealthcare facilities. All of the responses were then categorized into two groups: the screened group and the unscreened group. Differences among both groups were statistically analyzed. RESULTS: There were three main areas that significantly accounted for the discrepancies between the screened and unscreened groups: perceptions of discomfort from screening tests, psychological and behavior deterrents in CRC screening and diagnosis, and limited resources for accessing care, especially transportation. In particular, psychological and behavioral deterrents in CRC screening appeared to play a role in promoting aversion to CRC screening. CONCLUSIONS: Lack of CRC screening awareness and knowledge may be responsible for fatalism regarding CRC and aversion to screening. Thus, multidisciplinary interventions that provide education about CRC screening, early intervention prognosis, and treatment options, as well as addressing systemic barriers to screening, such as assistance with scheduling, prep instructions, and transportation, can improve the screening rate in Appalachia and eventually lead to better outcomes through the early diagnosis of CRC.

Dual role for angiotensin-converting enzyme 2 in Severe Acute Respiratory Syndrome Coronavirus 2 infection and cardiac fat.

Angiotensin-converting enzyme 2 (ACE2) has been an increasingly prevalent target for investigation since its discovery 20 years ago. The finding that it serves a counterregulatory function within the traditional renin-angiotensin system, implicating it in cardiometabolic health, has increased its clinical relevance. Focus on ACE2's role in cardiometabolic health has largely centered on its apparent functions in the context of obesity. Interest in ACE2 has become even greater with the discovery that it serves as the cell receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), opening up numerous mechanisms for deleterious effects of infection. The proliferation of ACE2 within the literature coupled with its dual role in SARS-CoV-2 infection and obesity necessitates review of the current understanding of ACE2's physiological, pathophysiological, and potential therapeutic functions. This review highlights the roles of ACE2 in cardiac dysfunction and obesity, with focus on epicardial adipose tissue, to reconcile the data in the context of SARS-CoV-2 infection.

Effects of Norepinephrine Infusion on Cutaneous Surface Temperatures of the Distal Extremities.

OBJECTIVES: The etiology of vasopressor-induced digital necrosis is poorly understood, but the skin changes resemble those of frostbite, and it is known from experience that patients taking vasopressors have decreased digital temperatures. We aimed to examine the effects of norepinephrine use on surface temperatures of the distal extremities because there have been no studies examining this relation. METHODS: Surface temperatures of all digits, palms, and soles were measured using an infrared thermometer in patients receiving different rates of norepinephrine infusion in the intensive care unit and compared with those not receiving any vasopressors. RESULTS: A total of 101 measurements from 41 unique individuals were obtained. Temperature gradients between the core and the fingertips were consistently more pronounced in those receiving norepinephrine compared with those not receiving norepinephrine and increased with increasing rates of norepinephrine infusion, except with high-dose norepinephrine. Temperature gradients were more pronounced in the toes. CONCLUSIONS: Norepinephrine use was associated with greater core-to-fingertip temperature gradients and were more pronounced in the toes compared with the fingers.

Benzodiazepine Overuse in Elders: Defining the Problem and Potential Solutions.

Objective To determine the prevalence of benzodiazepine use in adults aged 65 and older at two West Virginia academic medical centers as phase one of a benzodiazepine deprescribing strategy.  Design Cross-sectional Setting Two academic hospitals in West Virginia with 107,504 hospitalized adults age 65 and older from the years 2010 to 2018 with information on admission medication use.  Measurements Use of benzodiazepines based on presence on the admission medication list. Demographics, select co-morbidities, and laboratory tests were also recorded.  Results The prevalence of benzodiazepine use was 13.5% and use remained relatively constant with increasing age over 65, even in those over age 89.  Conclusion Efforts aimed at assessing the true need for benzodiazepine use and deprescribing need to be employed, particularly with advancing age.

Relationship between dietary sodium and sugar intake: A cross-sectional study of the National Health and Nutrition Examination Survey 2001-2016.

Dietary sodium intake and cardiovascular outcomes have a reported J-shaped curve relationship. This study analyzes the relationship between dietary sodium and sugar intake as a potential mechanism to explain this association. The authors examined cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2001-2016 where dietary sodium, carbohydrate, fat, cholesterol, and sugar intakes were assessed by 24-hour dietary recall and were standardized to a total daily intake of 2000 calories. Sodium intake was categorized into sodium quintiles (SQ) as follows: SQ1(0.06-2.6 g/d); SQ2(2.6-3.0 g/d); SQ3(3.0-3.4 g/d); SQ4(3.4-4.0 g/d); and SQ5(4.0-29.3 g/d). Simple and multivariate linear regression using SQ3 as reference were used to assess associations between daily sodium intake and the other nutrients. Our results showed that among 38 722 participants that met our study criteria, the mean age was 43.6 years (SD 16.8 years) and sex was equally distributed (48.8% male vs 51.2% female). Sugar intake went down across increasing SQs and was significantly higher in SQ1 (141.2 g/d) and SQ2 (118.6 g/d) and significantly lower in SQ4 (97.9 g/d) and SQ5 (85.6 g/d) compared to SQ3 (108.6 g/d; all P < .01). These same trends remained unchanged and significant in the fully adjusted multivariate model. In conclusion, NHANES study participants reporting low sodium intake on 24-hour dietary recall have a higher consumption of sugar. The negative impact of low sodium diet on cardiovascular health may be explained at least partially by the associated high sugar intake.

Antibiotic Prescriptions for Upper Respiratory Infections in a Pediatric Office Versus an Urgent Care Center.

It is estimated that as many as 10 million unnecessary antibiotic prescriptions are written each year for children. Children are more likely to receive antibiotics for an upper respiratory infection in an urgent care center compared with the primary care office. However, no study has examined the antibiotic prescribing practices of the same physicians in these settings. This retrospective chart review evaluated pediatricians' antibiotic prescribing practices for patients with symptoms of an upper respiratory tract infection in the office setting and an urgent care setting. There was no difference in the total antibiotic prescribing rate by pediatricians in their primary care office versus an urgent care setting. Pediatricians who were high antibiotic prescribers in the office setting were also high prescribers in the urgent care. The highest prescribing physicians prescribed the appropriate recommended antibiotics for a particular diagnosis the lowest percentage of the time. Efforts to promote antimicrobial stewardship should be directed toward the individual physician and not toward the location where the patients are being evaluated.

Comparison of Geriatric Trauma Outcomes When Admitted to a Medical or Surgical Service After a Fall.

BACKGROUND: Blunt trauma in the geriatric population is fraught with poor outcomes, with injury severity and comorbidities impacting morbidity and mortality. METHODS: We retrospectively reviewed 2172 patients aged ≥65 y who fell, requiring hospital admission between January 2012 and December 2016. There were 403 patients in the surgical arm (SA) and 1769 patients in the medical arm (MA). Ground-level falls were the only mechanism of injury included. We excluded all ICU admissions and deaths within 24 h. RESULTS: There were 5 deaths (1.24%) in the SA and 16 deaths (0.90%) in the MA (P = 0.57). The mean trauma injury severity score survival probability prediction in the SA was 96.9% versus 97.1% in the MA. MA patients had more comorbidities overall than SA patients. There was no difference in mortality between the SA and MA groups in multiple logistic regression models that accounted for trauma injury severity scores (TRISS) and comorbidities. Unadjusted hospital length of stay was 1 d shorter (median; 95% CI -1.4 to -0.6) in the SA and 0.5 d shorter (median; 95% CI -0.8 to -0.1) when adjusted for TRISS and comorbidities using multiple quantile regression. Finally, patients in the SA were 2.1 (95% CI 1.7 to 2.6) times more likely to be discharged home compared with patients in the MA, and this remained significant (OR 1.9; 95% CI 1.5 to 2.5) with simultaneous adjustment for TRISS and comorbidities using multiple logistic regression. CONCLUSIONS: Geriatric blunt trauma patients admitted to surgical services after mechanical falls have no difference in survival, a shorter median length of stay, and increased likelihood of being discharged home compared with patients admitted to medical services.

Later Stage Disease and Earlier Onset of Rectal Cancer: Epidemiology and Outcomes Comparison of Rectal Cancer in a Rural Appalachian Area to State and National Rates.

Although the overall rate of colorectal cancer (CRC) has remained stable, studies have shown an increase in the rate of CRC in young patients (<50) nationwide. We hypothesize that the rectal cancer (RC) rate in young people has increased in rural Appalachia. The goal is to provide insight into the future of RC epidemiology in underserved populations. This Institutional Review Board-approved retrospective study evaluated RC patients diagnosed in 2003 to 2016, and compared the ratio of early-onset RC to the state and national ratios using West Virginia State Cancer Registry, North American Association of Central Cancer Registries (NAACCR) and Surveillance, Epidemiology, and End Results Program Database. Demographics include age, gender, ethnicity, and county. We also evaluated cancer stage, family history, and comorbidities, including body mass index, smoking, and alcohol history. The rate of early-onset RC in our area is 1.5 times higher than the national rates. In our population, 100 per cent of patients were white with an equal gender distribution. Young patients with RC were noted to be more overweight than national rates. Young RC patients are more likely to have a first- or second-degree relative with cancer diagnosis. Smoking was strongly associated with young RC. Compared with national statistics, a higher proportion of young patients had Stage 1 or 2 disease which correlated with better survival. The rate of early-onset RC in the Tristate Appalachian area in West Virginia is higher than the national rate with risk factors including white ethnicity, obesity, diabetes mellitus, smoking, family history, and history of pelvic surgeries. It warrants further investigation and discussion of current CRC screening guidelines that begin at age 50.

Factors Associated with Functional Decline in Elderly Female Breast Cancer Patients in Appalachia.

Background Functional status has been previously shown in the elderly cancer population to predict both mortality as well as treatment tolerance. The goal of this study was to determine if there are certain subsets of the elderly breast cancer population that are at higher risk of experiencing functional decline following treatment. Methods Patient charts from the Edwards Comprehensive Cancer Center in Huntington, West Virginia, from January 2006 - January 2016 were reviewed. Relevant inclusion criteria included patients of 65 years of age and older with a new diagnosis of Stage 0-III breast cancer. Functional decline was defined as an increase of at least one point in Eastern Cooperative Oncology Group (ECOG) scores within one year of diagnosis. ECOG performance status was subjectively determined by the physician. Fisher's exact test and Pearson's Chi-squared test were initially utilized to assess potential factors associated with functional decline such as pretreatment ECOG score, age at diagnosis, stage, hormone receptor status, type of surgery received, whether radiation therapy, chemotherapy, or hormonal therapy was received, medical comorbidities, body mass index (BMI), complaints of weakness at diagnosis, and ambulatory status. Factors that were found to be significant were further assessed via multivariate logistic regressions. Results Three-hundred and fourteen patients were identified as meeting inclusion criteria. At one-year follow-up, 45 patients (14.3% of the cohort) had documented functional decline. On initial analysis, factors associated with functional decline included Stage III disease (p=0.002) and complaints of weakness at diagnosis (p=0.004). Following multivariate analysis, Stage III disease (p = 0.02), complaints of weakness at diagnosis (p = 0.04), and bilateral mastectomy (p = 0.03) were significantly associated with functional decline. Conclusion Patients who were diagnosed with Stage III breast cancer, had complaints of weakness at time of diagnosis, or had bilateral mastectomies were more likely to have a decline in functional status at one-year follow-up. Awareness of factors associated with functional decline in the elderly Appalachian population with Stage 0-III breast cancer will be useful during discussions regarding patient expectations, treatment, and goals of care. Elderly breast cancer patients for whom bilateral prophylactic mastectomies are not indicated may be better served by lumpectomy alone (based on patient age, hormone receptor status, and tumor size), lumpectomy followed by radiation therapy, or unilateral mastectomy to maximize the likelihood of functional preservation following treatment.

Outcomes After Open Reduction With Internal Fixation of Mandible Fractures.

INTRODUCTION/HYPOTHESIS: Mandible fractures contribute substantially to morbidity after blunt trauma. Controversy exists surrounding the appropriate timing of surgical intervention and benefit from routine postreduction imaging. METHODS: The authors retrospectively reviewed 146 patients who sustained traumatic mandible fractures at a level 2 trauma center over a 5-year period, between January 2012 and December 2016. The authors excluded all patients who did not undergo surgery, underwent operative closed reduction only, sustained other significant maxillofacial injuries, penetrating mechanisms, and other major injuries based on injury severity scores (ISS) over 15. There were 51 patients meeting inclusion criteria. The authors reviewed admission face computed tomography (CT) scans and Panorex x-rays. Patients were divided into early (<72 hours) and late (>72 hours) open reduction with internal fixation (ORIF) groups. The authors reviewed demographics, mechanism of injury, postreduction imaging, and ISS. All statistical analyses were performed using Stata 15. RESULTS: There were 39 males (76%) and 12 females (24%) in the authors' study, with a mean age of 32 years. Twenty-eight patients (55%) underwent early ORIF and 23 patients (45%) underwent late ORIF, with no mortalities. There was no statistically significant difference in ISS between the 2 groups (P = 0.081). Preoperative face CT scans were performed in 49 patients (96%) and Panorex in 2 patients (4%). Eight patients (16%) had both modalities, with CT face identifying fractures in 5 patients not seen on Panorex, resulting in a change in operative approach. Postreduction imaging was obtained in 33 patients (65%), of whom 26 were Panorex X-rays. These demonstrated adequate reduction in 31 patients (94%) and did not change management in any instance. Complications occurred in 19 patients (37%), of whom there were 11 with uncontrolled pain after 1 week, 6 abscesses, 5 nonunions/malunions, 2 hardware extrusions, and 1 incisional dehiscence. A positive urine drug screen predicted uncontrolled pain (P < 0.05). There was no statistically significant difference in complications between the 2 groups. CONCLUSION: The authors' data suggest that CT scans of the face are superior to panoramic radiographs in traumatic mandible fracture evaluation, with no apparent benefit from routine postreduction imaging in detecting complications. Open reduction with internal fixation remains an effective treatment with favorable outcomes, and operative delays > 72 hours do not appear to increase complication rates.

Effect of removing outliers on statistical inference: implications to interpretation of experimental data in medical research.

BACKGROUND: Data editing with elimination of "outliers" is commonly performed in the biomedical sciences. The effects of this type of data editing could influence study results, and with the vast and expanding amount of research in medicine, these effects would be magnified. METHODS AND RESULTS: We first performed an anonymous survey of medical school faculty at institutions across the United States and found that indeed some form of outlier exclusion was performed by a large percentage of the respondents to the survey. We next performed Monte Carlo simulations of excluding high and low values from samplings from the same normal distribution. We found that removal of one pair of "outliers", specifically removal of the high and low values of the two samplings, respectively, had measurable effects on the type I error as the sample size was increased into the thousands. We developed an adjustment to the t score that accounts for the anticipated alteration of the type I error (tadj=tobs-2(log(n)^0.5/n^0.5)), and propose that this be used when outliers are eliminated prior to parametric analysis. CONCLUSION: Data editing with elimination of outliers that includes removal of high and low values from two samples, respectively, can have significant effects on the occurrence of type 1 error. This type of data editing could have profound effects in high volume research fields, particularly in medicine, and we recommend an adjustment to the t score be used to reduce the potential for error.

Role of adipokines and inflammatory markers in postmenopausal hypertension.

BACKGROUND: The role of inflammatory markers and adipokines contributing to the development of postmenopausal hypertension, has not been established. The aim of our study was to assess the complex association between blood pressure, obesity, menopausal status, adipokines and inflammatory mediators in postmenopausal women. METHODS: We recruited 38 women seen at our Endocrinology Clinic and collected anthropometric measures and blood pressure and obtained serum samples for inflammatory markers and adipokine levels. Out of 38 women, 23 (60%) were postmenopausal. RESULTS: In the pre-menopausal and postmenopausal women, there were no significant differences in measured adipokines and inflammatory markers based on hypertensive status. When obesity was eliminated, significantly higher levels of EGF, IL-8, MCP1 and TNF-α and lower levels of IL-1α and IL-3 were observed in the postmenopausal group (P<0.05). Women with higher waist-to-hip ratio (WHR) had a significant trend towards lower adiponectin levels as compared to those with lower WHR (P=0.014 and P=0.04, respectively). CONCLUSIONS: There was a significant difference in pro-inflammatory markers in non-obese, pre- and post-menopausal women. These higher inflammatory markers might play a role in the development of post-menopausal hypertension.

A Free Clinic Continuity Experience During Residency Is Associated With Practice in Underserved Areas.

BACKGROUND: Exposure to underserved areas during training may increase residents' likelihood of practice in these settings. The Marshall University Family Medicine Residency offers a supplemental continuity experience at a local free clinic to interested residents. OBJECTIVE: We assessed the association of such an experience with graduate practice choices. METHODS: We evaluated all residency graduates (N = 138) who completed our family medicine program from 1997 through 2014 and compared participants in the free clinic experience to nonparticipants. Various characteristics and outcome measures were collected retrospectively from resident records maintained for program accreditation. RESULTS: A total of 43 residents participated in the free clinic experience compared with 95 nonparticipants. Postgraduation practice in an area of need was seen for 56% (24 of 43) of participants compared with 31% (29 of 95) of nonparticipants (P = .005). The 53 graduates practicing in areas of need were nearly twice as likely to have taken part in the free clinic experience (45% [24 of 53] versus 22% [19 of 85], P = .005). Participants were more likely to practice in rural areas (63%, 27 of 43) than residents who did not participate (43% [41 of 95], P = .033). Board certification rates were high for both free clinic participants (98%, 42 of 43) and nonparticipants (95% [90 of 95], P = .43). CONCLUSIONS: Resident participation in a supplemental continuity experience at a free clinic was associated with practicing in areas of need and rural communities after graduation.

Laparoscopic vertical sleeve gastrectomy: A 5-year veterans affairs review.

The aim of this study was to evaluate the outcomes after laparoscopic sleeve gastrectomy (SG) in a VA population.SG has recently gained popularity as a definitive bariatric surgery procedure. Data are lacking on long-term outcomes, particularly in a Veterans Affairs population.We retrospectively reviewed 223 patients who underwent SG for morbid obesity between January 2009 and June 2014. Data on length of stay, complications, interval weight loss, comorbidities, and number of therapies preoperatively and at long-term follow-up were collected.There were 164 males and 59 females who underwent SG. The mean body mass index was 45.4 kg/m. Mean excess weight loss at 1 year was 62.9%, and 47.0% at 5 years. Weight loss continued until 12 to 18 months, when there was a nadir in weight loss (P < .001). There were 4 deaths and 4 staple-line leaks, with 3 deaths related to late cardiac events. One early death occurred in a very high-risk patient. All staple-line leaks were managed nonoperatively. Of the 223 patients, 193 had hypertension, 137 diabetes, 158 hyperlipidemia, 119 obstructive sleep apnea (OSA), and 125 had gastroesophageal reflux disease. Preoperatively, patients were on a mean of 1.9 antihypertensive and 0.9 hyperlipidemic, anti-reflux and oral hypoglycemic agents. Fifty percent of patients with diabetes were on insulin and 68% with OSA used continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP). We found significant absolute reductions in mean antihypertensive medications (-0.8), hyperlipidemic agents (-0.4), antireflux agents (-0.4), oral hypoglycemics (-0.6), insulin use (-25%), and use of CPAP/BiPAP (-55%) (all P < .001).Laparoscopic sleeve gastrectomy is a safe and effective bariatric surgery procedure, resulting in significant early weight loss up to 18 months and long-term improvement in all major obesity-related comorbid conditions.

Three Decades of Follow-up of Adults After Recovery From Invasive Pneumococcal Pneumonia.

BACKGROUND: Streptococcus pneumoniae infection is the most common cause of community-acquired pneumonia in adults. Invasive pneumococcal disease (IPD) carries a high case fatality rate. We investigated the lifespan of adults who recovered from IPD during a 32-year follow-up. MATERIALS AND METHODS: We determined whether adults discharged after an episode of IPD from hospitals affiliated with the Marshall University Joan C. Edwards School of Medicine in Huntington, West Virginia from 1983-2003 were alive on June 30, 2014. Lifespan was assessed by Kaplan-Meier methodology, Cox proportional hazards multivariate analysis, life expectancy using life tables for West Virginia, years of potential life lost and serotype occurrence. RESULTS: The study group comprised 155 adults who survived IPD. They had a mean age at discharge of 64.6 years, mean lifespan after IPD of 7.1 years, mean expected lifespan after IPD of 17.0 years, mean age at death of 71.6 years and a mean life expectancy of 81.6 years. Only 14 (9.0%) patients lived longer than their life expectancy. Of the 13 comorbid diseases analyzed, cancer and neurologic diseases and the number of comorbid diseases suffered by each patient were the significant variables associated with survival. The mean years of potential life lost was 9.936 years. Only serotype 12 of 31 serotypes recovered occurred more often in patients who survived for 11 or more years after discharge (relative risk = 3.44, 95% CI: 1.19-9.95). CONCLUSIONS: The fact that most adult patients who recovered from IPD died before their documented life expectancy argues for the pernicious severity of IPD and the importance of immunization of adults with pneumococcal vaccines.

The Use of Telehealth to Teach Reproductive Health to Female Rural High School Students.

STUDY OBJECTIVE: To evaluate the use of telehealth to teach reproductive health to rural areas with high rates of teen pregnancy. DESIGN: Prospective cohort study. SETTING: Two high schools in rural West Virginia. PARTICIPANTS: High school female students who attended telehealth sessions. INTERVENTIONS: Teleconferencing equipment connected rural high schools to a distal academic institution. Telehealth sessions included reproductive health and life skills topics. Demographic information, session pre- and post-tests, and 6- month assessment was obtained. MAIN OUTCOME MEASURES: Reproductive health knowledge, behavior, and self-efficacy were assessed at intervention and at 6 months, along with Likert scale evaluation of telehealth as an educational tool. RESULTS: Fifty-five students participated in the program with an average age of 16.14 (SD 1.24) years. Only 20% (10/50) of subjects' mothers and 12% (6/50) of subjects' fathers had achieved education beyond high school, and 20% (10/50) of subject's mothers had experienced teen pregnancies (age 18 or younger). Sexual activity was reported among 52% (26/50) of subjects, 4/50 (8%) reported desire to become pregnant within the next year, and 4/50 (8%) reported already pregnant. Thirty-seven students completed the 6-month follow-up survey. Reported condom use increased from 20% (10/50) at baseline to 40% (15/37) at 6 months (P = .04) and hormonal contraception use increased from 22% (11/50) to 38% (14/37) (P = .12). Report of human papillomavirus vaccination increased from 38% (10/26) to 70% (26/37) (P = .001) among all subjects. At 6 months, 91.8% (34/37) reported the use of telehealth was "very effective" as a means to teach the material. CONCLUSIONS: Telehealth is an effective tool to teach reproductive health to rural areas.